Cognitive impairment in medical inpatients

Background: People aged over 80 years is the most rapidly growing segment of the population in Sweden. This group is susceptible to multimorbidity, disability and cognitive impairment. Managing these issues will be essential in order to obtain a sustainable healthcare system in the near future. Aim: To determine if increased acknowledgement of cognitive impairment could improve healthcare for elderly persons admitted to a general hospital Study population: Two hundred patients at the wards of general internal medicine at Skåne university hospital in Malmö. Results: I. Cognitive impairment was prevalent in 73% of medical inpatients, the majority of which were undetected by healthcare professionals. Cognitive impairment was independently associated with a three-fold risk of one-year mortality. II. A group of 99 patients received an intervention that focused on cognitive impairment. This group had fewer rehospitalisations after 12-months than the control group, receiving standard care. This effect was statistically significant for those patients who survived for 12-months, but not from an intention-to-treat perspective. III. In total, 94 patients had undergone a cranial computed tomography. Of these, 36% had an abnormal medial temporal lobe atrophy (MTA). None of these had been reported originally. Of the patients with abnormal MTA, 93% had cognitive impairment, with a test profile indicating a possible Alzheimer symptomatology. IV. An ADL (activities of daily living) measurement predicted mortality stronger than age, sex, body mass index, albumin, haemoglobin, kidney function and the Charlson comorbidity index. The ADL measurement entailed a substantial added value to these established risk factors. V. Lower quality of life was associated with cognitive impairment, ADL impairment, depression and social factors, but not with physical comorbidity. Conclusion: This thesis emphasises the need to acknowledge cognitive impairment in medical inpatients. The results suggest that increased acknowledgement of cognitive impairment could lead to fewer rehospitalisations, more accurate prognosis estimates and possibly better quality of life

Dementia with Lewy Body (DLB) Symptoms Hidden within the Diagnosis “Dementia Not Otherwise Specified” a Cross-Sectional Study in 40 Swedish Nursing Homes.

Background: Dementia with Lewy Body (DLB) is a neurocognitive disorder with core features, such as Parkinsonism, visual hallucinations, and fluctuating cognition/ excessive daytime sleepiness, and supportive features, such as rapid eye movement sleep behaviour disorder. DLB is often misdiagnosed and unrecognized in elderly individuals. A diagnosis of DLB is important because of the risk of hypersensitivity for neuroleptic drugs. Moreover, appropriate treatment of symptoms can improve quality of life considerably for both the individual with DLB and their caregivers. Primary care uses often diagnose Dementia Not Otherwise Specified (NOS) that may lead to an increased risk of wrong medical treatment and lack of proper elderly care. Especially if the elderly had a misdiagnosed or undefined DLB symptomatology. We hypothesized that potential DLB symptoms were hidden within the Dementia NOS diagnosis. Methods: A questionnaire designed to cover the main DLB symptoms (according to DLB consensus criteria from 2005) was distributed to all 40 primary care nursing homes (NHs) and geographically entirely covering the third largest Swedish city. Nursing staff completed the questionnaires after receiving specifically designed teaching. Results: The participants were elderly (n=650) from all NHs (n=40) where 94% (n=610) were included of which (n=595) had available medical records. The mean age was 86.0 ± 7.5 years; 75% (n=467) were women. The prevalence of elderly with Dementia NOS was 20% (n=121), AD 19% (n=115), AD-Mix 16% (n=97), VaD 14% (n=85), DLB/PDD 5% (n=22) and in 26% (n=155) no formal dementia diagnosis was found. Finally, according to the questionnaire, 16% of all the participants had two or more main symptoms of DLB (2-4 DLB smp.) According to the questionnaire, the elderly with the Dementia NOS diagnosis 85% had 0-1 DLB smp. and 15% had 2-4 DLB smp. Conclusion: We conclude that within the dementia NOS diagnose elderly with hidden DLB symptoms constitute 15% leading to risk of potentially harmful medication. Recognizing signs of dementia with Lewy bodies could reduce the number of individuals with Dementia NOS diagnosis and give opportunity to more suitable and less potentially harmful medication in nursing homes

Incidence, aetiology and temporal trend of bloodstream infections in southern Sweden from 2006 to 2019 : a population-based study

BackgroundBloodstream infections (BSI) are a public health concern, and infections caused by resistant bacteria further increase the overall BSI burden on healthcare.AimTo provide a population-based estimate of BSI incidence and relate this to the forthcoming demographic ageing western population change.MethodsWe retrieved positive blood cultures taken from patients in the Skåne region, southern Sweden, 2006-2019 from the Clinical Microbiology Department database and estimated incidence rates (IR), stratified by age (0-49, 50-64, 65-79, ≥ 80 years), sex, year, and species and described antimicrobial susceptibility for Enterobacterales.ResultsWe identified 944,375 blood culture sets, and 129,274 (13.7%) were positive. After deduplication and removal of contaminants, 54,498 separate BSI episodes remained. In total, 30,003 BSI episodes (55%) occurred in men. The overall IR of BSI was 307/100,000 person-years, with an average annual increase of 3.0%. Persons ≥ 80 years had the highest IR, 1781/100,000 person-years, as well as the largest increase. Escherichia coli (27%) and Staphylococcus aureus (13%) were the most frequent findings. The proportion of Enterobacterales isolates resistant to fluoroquinolones and third generation cephalosporins increased from 8.4% to 13.6%, and 4.9% to 7.3%, (p for trend < 0.001), with the largest increase in the oldest age group.ConclusionWe report among the highest BSI IRs to date worldwide, with a higher proportion among elderly persons and males, including resistant isolates. Given expected demographic changes, these results indicate a possible substantial future BSI burden, for which preventive measures are needed

Relative survival in patients with dementia with Lewy bodies and Parkinson’s disease dementia

IntroductionThe understanding of survival in dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD) is limited, as well as the impact of these diagnoses in an ageing co-morbid population.MethodsA retrospective study of 177 patients who received a DLB or PDD diagnosis between 1997–2014 at the Memory Clinic in Malmö, Sweden. Relative survival was evaluated by adjusting all-cause survival for expected survival, estimated from population life-tables, matched by sex, age and calendar year. Predictors of relative survival were investigated using multivariate regression modelling.ResultsAt follow-up, 143 (81%) patients were deceased with a median survival of 4.1 years (IQR 2.6–6.0). After 10-years follow-up, the standardized mortality ratio was 3.44 (95% CI 2.92–4.04). Relative survival was worse with younger age at diagnosis (excess hazard ratio [eHR] 0.91, 95% CI 0.88–0.94 per year of age), female sex (eHR 1.45, 95% CI 1.01–2.09) and lower mini-mental state examination (eHR 0.93, 95% CI 0.90–0.96). Subgroup analysis (n = 141) showed higher mortality in DLB patients who were positive for APOE ɛ4 (eHR 2.00, 95% CI 1.35–2.97).ConclusionThe mortality is over three-times higher in patients diagnosed with dementia with Lewy bodies and Parkinson’s disease dementia during a ten-year follow-up, compared to persons in the general population. Excess mortality is found primarily in younger patients, females and carriers of APOE ε4. Further research is needed regarding survival and possible interventions, including disease-modifying treatments, to improve care for this patient group

Fusobacterium necrophorum-PCR in pharyngotonsillitis - could the CT-value identify patients at risk for complications?

Background: Previously, we investigated tonsillar carriage of Fusobacterium necrophorum by PCR and found a high tonsillar carriage rate (21%) in asymptomatic 15-25 year olds, but the same age group is most commonly affected by severe F. necrophorum infections. Interestingly, we found Cycle threshold (Ct)-values in asymptomatic carriers to be high (median 29). Possibly, the Ct-value could differentiate between infection and tonsillar carriage, with bacterial load hypothetically being higher on infected tonsils. The purpose of this study was to investigate differences in F. necrophorum Ct-values in patients diagnosed with pharyngotonsillitis who did or did not develop complications. Methods: Patients with pharyngotonsillitis and positive F. necrophorum-PCR were enrolled from July 2016 - December 2020 in the Skåne Region, Sweden. Patients with prior complications or antibiotics (30 days) were excluded. Data was retrieved from registries and electronic charts. Patients were grouped by presence of any complication within 30 days, defined as a composite score of peritonsillar or pharyngeal abscess, otitis, sinusitis, sepsis or septic complications, chronic or recurrent tonsillitis (after 15-30 days) or hospitalization. Ct-values were presented with median and interquartile range (IQR) and compared with the Mann-Whitney U-test. Results: In total, 969 patients had pharyngotonsillitis and positive F. necrophorum-PCR. 29% developed complications. There was no difference in Ct-values between patients who did (median 21, IQR 19-25) or did not (median 21, IQR19-26) develop complications (p=0.51). Conclusion: In pharyngotonsillitis patients warranting extended work up for F. necrophorum, no difference in Ct-values between patients who did or did not develop complications was found. Most patients with pharyngotonsillitis had lower Ct-values than previously described in asymptomatic individuals, however factors such as degree of inflammation of tonsils, sampling technique and symptom duration were not accounted for

Multidisciplinary intervention reducing readmissions in medical inpatients: a prospective, non-randomized study

Background: The purpose of this study was to examine whether a multidisciplinary intervention targeting drug-related problems, cognitive impairment, and discharge miscommunication could reduce readmissions in a general hospital population. Methods: This prospective, non-randomized intervention study was carried out at the department of general internal medicine at a tertiary university hospital. Two hundred medical inpatients living in the community and aged over 60 years were included. Ninety-nine patients received interventions and 101 received standard care. Control/intervention allocation was determined by geographic selection. Interventions consisted of a comprehensive medication review, improved discharge planning, post-discharge telephone follow-up, and liaison with the patient's general practitioner. The main outcome measures recorded were readmissions and hospital nights 12 months after discharge. Separate analyses were made for 12-month survivors and from an intention-to-treat perspective. Comparative analyses were made between groups as well as within groups over time. Results: After 12 months, survivors in the control group had 125 readmissions in total, compared with 58 in the intervention group (Mann-Whitney U test, P = 0.02). For hospital nights, the numbers were 1,228 and 492, respectively (P = 0.009). Yearly admissions had increased from the previous year in the control group from 77 to 125 (Wilcoxon signed-rank test, P = 0.002) and decreased from 75 to 58 in the intervention group (P = 0.25). From the intention-to-treat perspective, the same general pattern was observed but was not significant (1,827 versus 1,008 hospital nights, Mann-Whitney test, P = 0.054). Conclusion: A multidisciplinary approach, targeting several different areas, could substantially lower readmissions and hospital costs in a non-terminal general hospital population

Hospitalisations with infectious disease diagnoses in somatic healthcare between 1998 and 2019 : A nationwide, register-based study in Swedish adults

Background: Several studies indicate increasing hospitalisation rates for specific infectious diseases (IDs). Studies describing the entire ID spectrum are scarcer. Our aim was to describe hospital use with ID diagnoses in Swedish adults from 1998 to 2019. Methods: All four-position codes in ICD-10 were reclassified as ID or non-ID diagnoses. Using data from the National Patient Register, age-standardised hospitalisation rates and average length-of-stay (LOS) was determined for hospitalisations with ID vs non-ID diagnoses in the primary position at discharge. The 22-year study period was divided into five periods that were compared using standardised rate ratios (SRR). Findings: Annual hospitalisations with ID diagnoses increased from 115 thousand in 1998-2002 to 182 thousand in 2015-2019, for a rate increase from 17·4 to 23.0 per 1000 person-years, and a SRR (95%CI) of 1.32 (1.32-1.33). Concurrently, the hospitalisation rate with non-ID diagnoses decreased from 147 to 110, for a SRR of 0.75 (0.75-0.75). Average LOS decreased less for IDs than for non-IDs. Consequently, the proportion of hospital nights for which an ID was considered causing the hospitalisation increased from 11% to 21%. Persons aged 80+ years had the highest ID hospitalisation rate. Interpretation: The increased hospital use with ID diagnoses suggests an increasing incidence of severe IDs as well as a changing case-mix of hospitalised patients. Given the anticipated demographic change, this trend is likely to persist. Healthcare systems will need to address IDs in a comprehensive and standardised way. Funding: Governmental Funding of Research within the Clinical Sciences (ALF